Referral & Registration

Are you referring someone?

You are welcome to fill out this form for yourself or another person.

This form includes everything MHP needs to know in order to register you or the person you are seeking care for. This form may be faxed, e-mailed, or hand-delivered to any MHP location. Additionally, instructions on how to fill out the form(s) may be obtained below.

Download

Instructions

Authorization to Release PHI (ROI)

Client Authorization to Release PHI (ROI)

When you send this online referral form to Mental Health Partners, the sensitive information you have put into this document will be secured. There is some risk that any information in this form may be disclosed to, or intercepted by, unauthorized third parties which are commonly referred to as hackers. If you prefer, you may drop off this form at any of our locations or mail it to Access Department, Mental Health Partners, 1455 Dixon Ave, Lafayette, CO 80026 or fax to 720-406-3606.

Referral Source Information

Referral Source

Referral Coordination?

YES

NO

Would you like MHP to coordinate your care with this agency/individual? If yes, please be sure to fill out a MHP Authorization to Release Information Form.

Contact Person

Contact's Info

New Client Information

Name*

FirstMiddleLast

Date of Birth*

Social Security #

Legal Gender

Gender Identity

Primary Language

Is a translator needed?

YES

NO

Street Address*

Street AddressCityStateZip Code

Phone*

Is it alright to leave a message on this number?

YES

NO

Other Phone

Private Email / Contact

Is the Client under 18?

YES

NO

Emergency Contact

Required for persons under 18

Emergency Contact

FirstLast

Emergency Contact Relationship to Client

Emergency Contact Phone

Emergency Contact Message?

YES

NO

Is it alright to leave a message on this number?

Primary Caregiver

Required for persons under 18

Primary Caregiver Contact

FirstLast

Primary Caregiver Relationship to Client

Primary Caregiver Contact Phone

Primary Caregiver Contact Message?

YES

NO

Is it alright to leave a message on this number?

Medical Decision Maker

Required for persons under 18

Medical Decision Maker Contact

FirstLast

Medical Decision Maker Relationship to Client

Medical Decision Maker Contact Phone

Medical Decision Maker Contact Message?

YES

NO

Is it alright to leave a message on this number?

Financials

Financially Responsiblel Party

the Client

Add Party

Financially Responsible Party

FirstLast

Financially Responsible Party Address

Street AddressCityStateZip Code

Financially Responsible Party's Relationship to Client

Financially Responsible Party Phone

Financially Responsible Party Message?

YES

NO

Is it alright to leave a message on this number?

Insurance #1

Insurance #1 Policy Holder Name*

FirstLast

Insurance #1 Policy Holder D.O.B.*

Insurance #1 Policy Holder Relationship to Client*

Insurance #1 Company*

Insurance #1 Company Phone

Insurance #1 Policy Number / Member ID*

Insurance #1 Group Number

Insurance #1 Group Name

Insurance #2

Insurance #2 Policy Holder Name

FirstLast

Insurance #2 Policy Holder D.O.B.

Insurance #2 Policy Holder Relationship to Client

Insurance #2 Company

Insurance #2 Company Phone

Insurance #2 Policy Number / Member ID

Insurance #2 Group Number

Insurance #2 Group Name

Income Information

In order for MHP to determine whether or not you may be eligible for a reduced fee under certain circumstances we need to gather some basic financial information.

Size of Household

Please enter a value between 0 and 999.

Please include yourself, spouse and any dependent children.

Gross Household Income

Please indicate whether this number is annual, monthly, etc.

Client Evaluation

The following questions are designated toward the Client, if filling this out as a Referral please answer as honestly as possible. If you are currently experiencing any of the issues below and would like to speak to someone right away, please call our 24/7 emergency team at 844-493-TALK (8225). You are also welcome to drop in any time of day or night 7 days a week at 3180 Airport Road, Boulder,CO 80301